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F OBENEFITS BENEFITS S A <br />T "T <br />O <br />ESTATE ATEIMPROVEMENTS <br />State Form 51767 (R4 i 2-13) <br />Prescribed by (he Department of Local G . �qvernrnent Finance <br />This sta!ern6nt is being qo#ietod'for real property fa <br />yjha�-�'4ia!lflep under The following Indiana (check one box): <br />❑ Redevelopment or rehabilitation of real es I tatej . mprovements. (16 - 64AA2.1-4) <br />11 Residentially distr6sted area (106- l.i-i2.1-4.1) <br />1. TVs statement inust <br />in <br />Aribm. Ildeits the 'Osig nating bodyfigFOREthe redel <br />Projeds"filarned or &MmlWd to aftrJo[y i, <br />1987, <br />2. Cobh(ZM, R6ri <br />(City <br />the Ec0#oM1& A&vbJ1zq11on AMq prior to the pUblic.hearin,q if ifia-desi-driaft bddy, reqdlirdi <br />whetberto d e8 ' goa t e" an Economic R <br />e v" '1z <br />Hop A rea, <br />0 <br />1 <br />8 s <br />la4o <br />Went r f e *a f On o ' M al! "p 0 ! ri "epe'son wishes s t at ma de <br />areas d as g no t a d S# er 4 U � 1 198 7 M q V STATEMENT OBENEFITS F <br />a , County Coana e� ) MU 0 b 0 .obtained p d or to I 4 lat on of them e p ea br <br />" <br />.3, To ' h a ' deduci 6n a Fom q221RE must b0%ed with th6 Cotr7tyAudb?bd0rpMay 101r the, year lh which the addition to assessed valuation is. <br />made or trot lafer titan thirty (30) days a qer "hj6hiridif06 is mailed to the property owner if it was mailed afterApal ia ff the propequirowfier- <br />eq;s9s;.. <br />ind'Maylooeasubsequent "yeAr <br />inrsses the May 1p deadline fn the inidal yeaY of occupatign he can apply <br />botiveen March I i <br />"'fi3 fft' �i6vedbkbtJane, ' ji iii <br />4. Property oy�ne& Whose Stiiieiiiik 0 a r-;n� <br />Benefits "S Ap, 30i .1 91. must at CF-IlReal Property annuaily to the appjjcati n to <br />show compliance with the Statement.,afBenetfts., (IC 6- 1.1- ?2151(4) and <br />s., 71�ie schedules gglebliihiiit andir!C fbr0*b#A4e �.Orop IT, vitalizellonarazisdeslahateda erJune-20,2000, <br />unless 04yapP. to ft <br />an memative. deduction. schedule 1-111-11), The schedules prior to July 1, 2000, *hall <br />. j# <br />V4 <br />SECTION I TAXPAYER INFORMATION <br />Nomeaftaxpayer <br />South Send Form Too] Co., Inc. <br />Address of (akpayer (0trMber an# street, ON state, and ZIP ccde) <br />408 W. Indiana Ave., South Bond, IN 46613 <br />Na" of omlaqt parson aph <br />Tel one nurnbif --rg-M211 <br />address <br />Herb Eggers (574 289-2441 <br />beggers@sbform.com <br />SECTION Z LOCATION AN • DES CR IPTION . • PROPOSED PROJEGV-,7 <br />Name of designating body <br />Resolution number <br />City of South Send <br />Lqcapon of property <br />County <br />DCGF Wing district number <br />1619 & 1623 Franklin St., South Send, IN 46613 <br />St. Joseph <br />Description of real property lmprovernents; redevelopmeint, or iWja­b8I1atIqn (;sp adcq4(malshepts ifnecessary) Estimated start date.(monh day, year) <br />4/112016 <br />Construction ol'approximately 3,000 additional square feet of manufacturing space and Improvements to existing building .-E-V-M--tW Privet Ion, 4its, (.A day, Y-4 <br />12/VO16 <br />CU rfe nt. mumber Salaries NurnbiWielalned salaries Numbs <br />17 $785,000 17 $785.00D 8 1$378.560 <br />• ESTIMATED TOTAL COSTAND.V4LUE <br />SECTIN 4 <br />• PROPOSED PROJECT <br />FUL, ESTATE IMPROVEMENTS <br />-COST <br />ASSESSED VALUE <br />values <br />$10,000 <br />$31.000 <br />Pigs estlinated vilums of, ro'oosad prqjept <br />$222.I66 <br />$222,166 <br />Less values qfa rope.riybeft replaced <br />$0 <br />$a. <br />Net estiinilOd values .upon boiri pjSfi on 0 0rQ@9! — <br />$232,166 <br />$253,166 <br />SECTION 5 - WASTE CONVERTEDAND O-THER <br />BENEFITS PRONIISED BY.T1HE--TAX PAYER <br />Estirritited sold waste converted (pounds) <br />Estimated hazardous waste converte . d (poijnds) <br />Oftrbenefits <br />SECTION 6 TAXPAYER CERTIFICATION <br />I I" hereby . . . i 1 6 A . iti Wt the representations . <br />s 6 this statement are true: <br />Signature oratillic 2i^ ipresentative Digitally signed by Kyle Harbison <br />Date: 2016.03.0311:30:24 -05'00' <br />Project Manager <br />alp signed e&qhth, day, yLaFo <br />3/03/2016 <br />Page I of 2 <br />